Application

Student Name
 
Birth Date
 
Gender
 
Address
 
City
 
State
 
Zip
 
Current School
 
Current Grade
 
Medical issues
 
Medical needs
 
Medication allergies
 
Food allergies
 
Other allergies
 
Special dietary needs
 
Additional medical information
 
Questions or Comments
 
Parent Information
 
Father's Name
 
Cell Phone
 
Email
 
Highest Level of Education Attained
 
Mother's Name
 
Cell Phone
 
Email
 
Highest Level of Education Attained
 
Student Information
 
Intended Student Start Date
 
What is the first language this child learned to speak?
 
What language does this child speak most often outside of school?
 
What language do people usually speak in this child’s home?
 
Is this student currently under suspension/expulsion from another school?
 
Has this student previously received special education services?
 
Is this student currently receiving special education services?
 
I give my consent for emergency medical treatment for my child. In the event of illness or injury requiring emergency treatment, I give permission for the school authorities to take action.
 
I, the parent, hereby give my consent to all photographs, audio recordings, academic work, and/or video recordings taken of me or my minor child by Annoor Academy of Knoxville staff or their designee.
 
Is there anyone who DOES NOT have permission to pick up student? (Please list name and relationship)
 
Alternative Contact / Pickup (Name and Phone number)
 
Financial Information
 
Tuition Payment Method:
 
Account holders name as shown on account:
 
Banking Routing /ABA Number:
 
Bank Account Number:
 
Credit Card Number
 
Cardholder Zip Code from credit card billing address:
 
Card Number Expires:
 
Electronic Signature
 
 
Upload Current Immunization Record and Birth Certificate
 
 
 
 
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